Blind nasotracheal intubation in the presence of facial trauma

Transoral approach in facial penetrating trauma - importance of multidisciplinary management and nutritional support a case report

The high incidence and prevalence of facial trauma makes it important to consider related injuries and possible complications that may arise as a result. Penetrating trauma to the face, although not common, requires a surgeon with knowledge of the anatomy and physiology of the injured area and injury patterns.

We present a case of penetrating trauma to the face that was caused by a blunt object (stake) resulting from the felling of a palm tree. We describe the transoral management that was performed and the multidisciplinary support that allowed optimal management of the injury without complications, including functional or aesthetic sequelae.

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The high incidence of facial trauma makes it crucial to consider related injuries and possible complications.

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This article may help other physicians in the emergency setting managing similar injuries.

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Transoral extraction of the foreign body may the best approach for some penetrating injuries. The surgeon must anticipate the possibility of other procedures in order to allow breathing and obtain nutritional support.

Fibreoptic intubation in airway management: a review article

Since the first use of the flexible fibreoptic bronchoscope, a plethora of new airway equipment has become available. It is essential for clinicians to understand the role and limitations of the available equipment to make appropriate choices. The recent 4th National Audit Project conducted in the United Kingdom found that poor judgement with inappropriate choice of equipment was a contributory factor in airway morbidity and mortality. Given the many modern airway adjuncts that are available, we aimed to define the role of flexible fibreoptic intubation in decision-making and management of anticipated and unanticipated difficult airways. We also reviewed the recent literature regarding the role of flexible fibreoptic intubation in specific patient groups who may present with difficult intubation, and concluded that the flexible fibrescope maintains its important role in difficult airway management.

Is nasotracheal intubation safe in facial trauma patients?

BACKGROUND

In the prehospital setting, oral intubation is preferred in facial trauma patients due to the potential for further injury during nasotracheal intubation. This study compared the complications of nasal vs. oral vs. nasal + oral intubations performed by first responder crews in facial trauma patients. Our objective was to assess patient outcomes and complications to determine the risk of nasal intubation in facial trauma patients in the prehospital setting.

METHODS

Patients with facial trauma between 2008 and 13 were abstracted from the Miami Valley Hospital trauma registry: 50 were nasal only (n), 27 nasal + oral (no), and 135 oral only (o) intubation. Analysis of variance with the post-hoc Least Significance Difference Test and the chi square test were used in the analysis.

RESULTS

The oral group was older [41.1 ± 17.6 (o) vs. 36.2 ± 14.1 (n) vs. 33.0 ± 15.7 (no), p = 0.032] and had a higher facial abbreviated injury severity (AIS) mean score (1.8 ± 0.6 vs. 1.3 ± 0.5 vs. 1.5 ± 0.5, p < 0.001). The three groups did not differ in mortality (n = 20% vs. o = 18% vs. no = 30%, p = 0.37). The n + o group was intubated longer (p < 0.001) and had longer ICU and hospital lengths of stay (p = 0.015 and p = 0.023). The three groups did not differ on the composite of any pulmonary complication - i.e., any one of sinusitis, pneumonia, atelectasis, and respiratory failure - 44% (no) vs. 24% (o) vs. 30% (n), p = 0.10). However, nasal + oral patients were more likely to have one or more of the eight complication studied [63% (no) vs. 28% (o) vs. 34% (n), p = 0.002], and have a longer ICU and HLOS.

CONCLUSIONS

Prehospital nasal intubation is a viable short-term alternative to oral intubation in patients with facial trauma and warrants further research.

Management of maxillofacial trauma in emergency: An update of challenges and controversies

Trauma management has evolved significantly in the past few decades thereby reducing mortality in the golden hour. However, challenges remain, and one such area is maxillofacial injuries in a polytrauma patient. Severe injuries to the maxillofacial region can complicate the early management of a trauma patient owing to the regions proximity to the brain, cervical spine, and airway. The usual techniques of airway breathing and circulation (ABC) management are often modified or supplemented with other methods in case of maxillofacial injuries. Such modifications have their own challenges and pitfalls in an already difficult situation.

Critical airway skills and procedures

Airway management is a critical procedure and essential skill necessary for all physicians working in the emergency department. Optimal resuscitative treatment of medical and trauma patients often revolves around timely and effective airway interventions that can be challenging in the acute setting, especially in critical patients. Time-honored airway techniques and procedures combined with recent advances in rapid sequence intubation, video laryngoscopy, and further advanced airway techniques now offer emergency clinicians a wide range of exciting new options for improving this crucial component of acute care and management.

A complication of nasotracheal intubation after mandibular subcondylar fracture

Among the potential risks of nasotracheal intubation are nasal bleeding, sinusitis, bacteremia, accidental turbinectomy, and some other structural damages. Retropharyngeal dissection is reported as a very rare complication of nasotracheal intubation, mostly encountered in elective surgery patients. A case with traumatic subcondylar fracture of the mandible is presented here, which is suspected to be the cause of the nasopharyngeal dissection that was observed during attempted nasotracheal intubation.

Comprehensive airway management of patients with maxillofacial trauma

Airway management in patients with maxillofacial trauma is complicated by injuries to routes of intubation, and the surgeon is frequently asked to secure the airway. Airway obstruction from hemorrhage, tissue prolapse, or edema may require emergent intervention for which multiple intubation techniques exist. Competing needs for both airway and surgical access create intraoperative conflicts during repair of maxillofacial fractures. Postoperatively, edema and maxillomandibular fixation place the patient at risk for further airway compromise.

A review of intraoperative airway management for midface facial bone fracture patients

In craniofacial trauma patients, oral route endotracheal intubation may thwart the accuracy of dental occlusion and nasotracheal intubation carries the risk of intracranial invasion in skull base fracture cases. Between November 2005 and June 2006, patients receiving facial bone fracture operations at Kaohsiung Medical University Hospital were enrolled in this study. Intraoperatively, the endotracheal tube was pushed to either the retromolar space or the missing tooth space and secured by two 4.0 silk stitches. Then, surgeons could perform the usual procedure to explore the fracture sites, check the occlusion and correct the deviated nose without limitation. Also, for better understanding the time needed for various intubation techniques, a time-measuring study was performed. Ninety-one patients were treated by this method. Most of them were satisfied with the result of occlusion and nasal contour. Only 2 patients received second surgery to correct nasal deformity. One hundred seventeen anesthesia procedures were checked. In average, an experienced anesthesiologist could successfully intubate a patient in less than 105 seconds. The advantages and reported complications of different intubation methods were discussed. This retromolar position and tooth fixation technique allowed surgeons to correct the dental occlusion and nasal deformity simultaneously. It has served well for zygoma fracture, maxilla fracture, and Le Fort II fracture patients. It is worthy of consideration in management of middle face trauma patients involving occlusion change and nasal deviation.

External carotid arterial injury

Carotid vascular trauma has high mortality. The two primary causes of death are associated head injury and vascular injuries that cause exsanguination or stroke. In the past two decades interventional radiology, i.e. techniques of transcatheter embolisation, has become a vital component of the care of these cases. External carotid artery injuries are complex and are often inaccessible causes of exsanguinating haemorrhage. Transcatheter techniques have been shown to be highly effective in controlling this haemorrhage. An overview of injuries of the external carotid artery and its branches is presented.

Early management of the traumatized airway

Penetrating face and neck trauma is usually obvious, but blunt trauma mandates high index of suspicion to recognize its existence. Comprehensive understanding of the injury is mandatory to plan the best timing and method to secure the airway.

Airway management in neurological emergencies

Several neurological conditions may present to the emergency department (ED) with airway compromise or respiratory failure. The severity of respiratory involvement in these patients may not always be obvious. Proper pulmonary management can significantly reduce the respiratory complications associated with the morbidity and mortality of these patients. Rapid sequence intubation (RSI) is the method of choice for definitive airway management in the ED and is used for the majority of intubations. The unique clinical circumstances of each patient dictates which pharmacological agents can be used for RSI. Several precautions must be taken when using these drugs to minimize potentially fatal complications. Noninvasive positive pressure ventilation may obviate the need for intubation in a select population of patients. This article reviews airway management, with a particular emphasis on the use of RSI for common neurological problems presenting to the ED.

Intracranial placement of a nasotracheal tube after transnasal trans-sphenoidal surgery

Intracranial misplacement of a tracheal tube during attempted nasotracheal intubation is a rare, usually lethal complication. Such incidents are associated with fractures of the face and base of the skull. We report inadvertent intracranial placement of a nasotracheal tube in a patient who had 2 weeks previously undergone transnasal trans-sphenoidal surgery for a pituitary tumour. One should be aware that transnasal trans-sphenoidal surgery leaves a bony defect in the skull, which is susceptible to perforation by nasally introduced tubes.

New equipment and techniques for airway management in trauma

A patent, unobstructed airway is fundamental in the care of the trauma patient, and is most often obtained by placing a cuffed tube in the trachea. The presence of shock, respiratory distress, a full stomach, maxillofacial trauma, neck hematoma, laryngeal disruption, cervical spine instability, and head injury all combine to increase tracheal intubation difficulty in the trauma patient. Complications resulting from intubation difficulties include brain injury, aspiration, trauma to the airway, and death. The use of devices such as the gum-elastic bougie, McCoy laryngoscope, flexible and rigid fiberscopes, intubating laryngeal mask, light wand, and techniques such as rapid-sequence intubation, manual in-line axial stabilization, retrograde intubation, and cricothyroidotomy, enhance the ability to obtain a definitive airway safely. The management of the failed airway includes calling for assistance, optimal two-person bag-mask ventilation, and the use of the laryngeal mask airway, Combitube, or surgical airway. The simulation of airway management using realistic simulator tools (e.g. full-scale simulators, virtual reality airway simulators) is a promising modality for teaching physicians and advanced life support personnel emergency airway management skills.

Nasotracheal intubation in the emergency department, revisited

This retrospective study was designed to investigate the current practice of nasotracheal intubation (NTI) in the Emergency Department (ED) at the University of California, San Diego Medical Center. Over a 5-year period, 21% (105/501) of patients intubated in the ED had at least one NTI attempt. The most frequent primary diagnoses in these patients included drug overdose, congestive heart failure, and chronic obstructive pulmonary disease. We report an overall NTI success rate of 79% (83/105). Sixty-one percent (64/105) of the patients were nasally intubated on the first NTI attempt. Nasal dilators, topical neosynephrine, and sedation improved NTI success rates. Epistaxis and improper tube position were the most common immediate complications. Sinusitis, pneumonia, and sepsis were the most frequent late complications. Patients receiving thrombolytic therapy were at risk of developing severe epistaxis. A prior history of sinus disease may predispose a nasally intubated patient to sinusitis. The complication rates reported here are similar to those of previous studies. A survey of emergency medicine (EM) residency programs found that EM residents throughout the country perform an average of 2.8 NTIs during their residency training. Thus, there is limited exposure to this intubation technique in EM residency programs. Nasotracheal intubation is a useful alternative to oral intubation, particularly when oral access is compromised. While not the optimal approach, we conclude that NTI is still a valuable method for establishing an airway and should remain among the emergency physician's arsenal of intubation techniques.